Latest Report on Air France 447 Crash Still Blames Pilots, Training

There was plenty of backlash when I wrote about the causes of the 2009 crash of Air France flight 447 into the Atlantic Ocean back in May. Many of you wanted to wait until the final report came out, but I was confident that the story had become quite clear. With the latest interim report (which I can only find in French – summary in English is here), it looks like I was right on track.

Un Airbus A330 d'Air France

Here’s what I said at the end of my last post:

Remember, the pilots were already working to pick their way through the worst of the storms. Add to that the loss of the autopilot, dozens of failure messages, and inconsistent speed readings and it seems like the answer might be simple. The pilots may have been so distracted that they forgot to do the one thing they needed to do to survive: fly the airplane. Once the final report is issued, look for training changes to come out of this and possibly even some changes in the way Airbus puts its airplane logic together.

Sure enough, the focus of the latest report is on training and puts a lot of the blame on Air France, but there is some discussion about aircraft logic as well. This has been enough for the investigators to push out safety recommendations, though not without controversy.

Throughout this 3rd interim report, a picture of normalcy is painted throughout the beginning of the flight. It was noted that when the Captain left to take his rest, he didn’t leave “clear operational instructions” and there was “no explicit task-sharing” between the two remaining pilots, but the crew composition was fine and the aircraft weight and balance was within the proper limits.

As mentioned in the last report, the crew was well aware of the weather ahead and had made course corrections to avoid the worst of it. That’s when things got ugly.

According to the report, the aircraft was flying at the “upper limit of a slightly turbulent cloud layer” when the autopilot disconnected. It’s believed that this happened because the pitot tubes froze over and that gave the aircraft incorrect speed information. When the system can’t make sense of the information it’s being fed, it shuts off autopilot and the pilots have to fly the airplane. Turbulence, however, was not a problem. The plane was perfectly flyable, but poor decision-making fed by weak training brought the airplane down.

Proper procedures were not followed for dealing with unreliable airspeed indication. To make things worse, neither of the two copilots had been trained to properly handle manual flying at high altitude. Despite the stall warning, the pilots continued to apply nose-up pressure, the opposite of what they should have done. In less than a minute, the plane went from being correctable to operating outside the design limits because of the improper recovery efforts by the pilots.

About 1 minute and 30 seconds after the autopilot disconnected, the Captain came back into the cockpit. At this point, stall warnings were going on and off and the airplane was still at 35,000 feet. Unfortunately, it was also losing 10,000 feet per minute as forward speed just disappeared. At times, the aircraft rolled from side to side as the pilots struggled to get the airplane under control. Those in the back must have felt sheer terror. The pilots never made an announcement to the passengers, and soon after, they all plunged into the Atlantic. I get goose bumps just thinking about how awful that must have been.

So after all that, what have we learned? We know the aircraft functioned properly. Were it not for the pitot tubes freezing over, this would have been a routine flight. Even when the pitot tubes failed, had the pilots been able to properly fly the aircraft manually, the passengers probably wouldn’t have even known there was an issue. Out of this, the French accident investigators have released safety recommendations that will need to be implemented by regulators in order to go into effect.

The main recommendation is around training. The idea is to make sure that all pilots have the proper training for manual flight at high altitudes, a skill which is rarely used in commercial aviation today. There is also additional training suggested around stall avoidance and recovery. Additionally, it’s suggested that the role of relief captain should be better-defined when the Captain is on rest. This way, there will be less confusion and more defined task-sharing if something goes wrong.

But the blame wasn’t solely on the training and pilots. One recommendation for aircraft manufacturers is to look at including an angle of attack indicator that pilots can see on the flight deck. There is an indicator showing the angle of the aircraft to the ground, but there isn’t one that shows the angle of the wing as compared to the direction of the air (angle of attack). That could have helped the pilots in their recovery efforts.

One recommendation not made was to revisit the way stall warnings are handled on the A330 aircraft. In fact, the pilots union at Air France is so angry about this being left out that it has decided to stop cooperating with the investigation. The on-and-off nature of the stall warning may have simply added to the confusion, and made it more difficult for the pilots to make the right moves. The investigators say that there wasn’t enough evidence to include this just yet, but it will be discussed in some form in the final report.

Regardless of what comes out in the final report, the picture is already very clear. It seems that current pilot training standards were not enough to help these pilots get out of an entirely recoverable situation. Were the Brazilians running this investigation, they probably would have already filed criminal charges against anyone they could, but the French handle this properly. Find the problem, fix the holes, and make sure that something like this never happens again.

[Photo of Sister Ship to Crashed Airplane via Flickr user Tab59|CC 2.0]

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34 Comments on "Latest Report on Air France 447 Crash Still Blames Pilots, Training"

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Stephen
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Cranky, you do a great job here…but no need to tout your own horn so much in the beginning. We can read your blog and know you do a good job (why you have so much return traffic..) – you don’t need to prove anything to your readers here. Just let the words speak for themselves. You’re got a highly successful thing going here

Austin
Guest

Good discussion, but don’t be so quick to praise the French over the Brazilians. Don’t forget that the French did (and continue) to engage in criminal prosecutions over AF4590 (the Concorde crash) against Continental and Continental employees. Granted, they did wait several years to do so, but they are still among the few countries in recent history to engage in criminal prosecutions as a result of a civil aviation accident.

Bill Hough
Guest

I was going to bring up the same point, I think there have been some good op-eds on the subject over the years and there’s this 4 agency resolution on the subject: http://flightsafety.org/files/resolution_01-12-10.pdf

Eric
Guest
There’s not a pilot alive who doesn’t look at this accident and wonder what the AF pilots were thinking by climbing steeply. To suggest they need training to avoid doing that is about as sensible as suggesting that drivers need to be taught not to drive into brick walls. It’s just that fundamental to basic flying. There must be more to it. I wonder if this doesn’t illustrate the inability of the human brain to deal with novel, high sensory input situations, especially when life is on the line. Two thoughts on implications not yet mentioned. First, what will this… Read more »
aeronathan
Guest

Glad somebody said it. When I was pursuing my engineering degree, I did about 10 hours of flight training before I ran out of money. I was maybe hour 2 or 3 into it when my instructor started teaching me stalls and stall recovery.

I mean quite honestly, “don’t keep pulling the nose up in a stall” is Piloting 101. Drop the nose, build some airspeed and drop the AOA. Rule #1 is always keep the airplane flying because bad things tend to happen when it stops flying.

Wei
Guest
There’s a lot of amateur pilot / general aviation types all over the Internets and on the news being armchair quarterbacks on this thing, saying stuff like “geez I learned to recover from / prevent a stall in my Cessna, so these French guys are idiots”. I have two words for you: COFFIN CORNER. Read about this phenomenon and you’ll realize that high-altitude aviation is a whole different ball o’ wax, and that your PPL/MPL knowledge is worth almost nothing once you’re zipping around the stratosphere. If you want to understand the situation properly, read the BEA report in its… Read more »
Eric
Guest
There’s also a lot of highly experienced airline pilots such as myself saying the same thing, not just armchair PPLs. There’s no excuse for pulling the nose into a 7000fpm climb with >10 deg pitch up at FL350 in any airliner. It’s not something done deliberately. It’s either distraction, inadvertent, or clumsy attempt at the loss of airspeed data procedure. If it was intentional it wasn’t done with rational thinking. Either way, it’s not something that pilots need to be told not to do. There’s an insidious feeling that develops after thousands of hours flying airliners that they are somehow… Read more »
MathFox
Guest
Erik: “There’s an insidious feeling that develops after thousands of hours flying airliners that they are somehow immune from stalls” It is very strong for Airbuses: in “normal control law” the fly-by-wire system does not allow pilot inputs to stall the plane. Normally, an Airbus pilot will not be able to stall his plane with joystick inputs alone. However, pretty soon after autopilot disengagement, the fly-by-wire system changed to “alternate law”, dropping the stall protection ‘filter’ from the control input processing. In alternate law it IS possible to stall an Airbus. I look at it from the view of a… Read more »
aeronathan
Guest
Well, this “amateur pilot / general aviation type” also happens to have a BS in aerospace engineering, emphasis in flight mechanics and quite a few years experience working aircraft performance, so I think I’ve already got a pretty firm grasp of “coffin corner” along with the remainder of the flight envelope and the nitty gritty of flying in it. :p Even if you’re experiencing a stall up in the coffin corner, the last thing you should do is keep pulling the nose up, because all it will do is bleed airspeed, increase AOA and worsen the stall condition. In fact,… Read more »
Nick Barnard
Member

Eric, regarding the computing power, the A330’s design dates from around the late 80s. I’m sure there have been some updates, but thinking through a redesign like you’re suggesting is probably more than Airbus could justify from a market perspective, and it’d probably take a good amount of testing to ensure that the sensors don’t cause some sort of loop upon themselves.

I’d hope that the A350, A380, 747-8 and 787 have this type of logic built in from the onset.

jlb54061
Member

Cranky, I am a big fan of this blog….but come on, don’t break your arm patting yourself on your back or anything. Your faithful readers know you were right, you don’t have to force feed us. Your humility has always been one of your best assets.

David SF eastbay
Member

Think I read something not to long ago about the more automation in the cockpit the less pilots will know what to do if they had to do it themselves. Not the exact wording, but you all know what I mean.

davidthomson_98
Member

Cranky, I´m a big fan but praising the French for not filing criminal charges is “criminal!” Do you forget the pending charges against Continental at present over the Concorde crash? The only reason the French haven’t filed charges is because its an Airbus (partially French company) and Air France, (a French carrier) If this had been a Boeing airliner and/or other Foreign carrier, the magistrates in the French courts would have been having a field day!

derek.a.stewart
Member

Eric makes a good point about training. I think there is fundamental human trait here that the 2 relief pilots did not have (and maybe the captain): the ability to deal with things in a high state of pressure and resolve them. Some people can deal with high pressure circumstances, others just freeze and can not make even the simplest decision in a crisis.

Thanks for keeping us up to date on this. Thanks.

Peter Mac
Member

First of all, my clear recollection of training for stalls is: nose down, nose down, nose down! (and yes to the ‘experts’ I have high altitude experience). Also, what happened to the heated pitot tubes? And there is redundancy there, so did they ALL fail at the same time?

Wei
Guest

It’s more than a mere need to nose down.– we’re talking about loss of situational awareness. Night flight over water, essentially instrument-flight-rules but with loss of valid instrumentation. Plus current training is NOT simply nose-down — nose-down is simply one of many trained solutions to many scenarios for heavy transports at different altitudes.

Again, read the BEA report (the full English version is available now) in its entirety, and also read the airliners.net thread I mentioned. Your questions and many more have been raised and discussed in exhaustive detail there.

EagerTraveler
Guest

I haven’t wanted to fly them since the YYZ accident. I’m in no hurry to try out Qantas given there years of issues as well.

djsk
Guest
I hate to jump in, but the “nose down” comments don’t acknowledge transport category aircraft stall training up to this point so they aren’t really accurate. Unfortunately there was a lot of negative learning involved with stall training, usually involving pulling like crazy on the yoke as the aircraft slows down without retrimming, and then powering out at the stick shaker, or before the stall has occurred. Its was never “nose down”, it was always “power out” with minimal altitude loss (less than 100 feet), which works during an approach to stall but not in this situation. It really is… Read more »
djsk
Guest
And too add more clarity, from my experience stall training used to look like this: -engines to idle, airplane starts to slow. -You pull and add trim to maintain altitude, this takes a while, you are pulling and trimming for 30 seconds + -At some point you are no longer allowed to trim and have to really pull the nose of the airplane up to maintain altitude as the aircraft slows -stick shaker, etc… announces the stall is close, maintain the pull and add full thrust to recover Stop right there and take a picture of what is happening. It… Read more »
Dan
Guest
I’ve got my PPL too, and if there’s one thing I learned from working around large airplanes over the years is that I know next to nothing about them. Now, I always assume that the human brain is somewhat rational. In this case, the pilots did what they did for a reason. The key here is trying to reverse engineer their thought process and see what lead to them thinking what they did. Only then can we really learn from this crash. Despite the fact I’m no psychologist, I’m a big big fan of human factors work. Generally speaking, I… Read more »
Adam Shaw
Guest
Hello: FYI: Le Figaro, French equivalent of the New York Times today published a piece stating that the BEA (French NTSB) only released 10 minutes of the 2 hours of Cockpit Voice Recorder (CVR) they have for the Rio-Paris AF # 447 crash because other moments reflect very poorly on the competence and professionalism level of that particular Air France crew. Not released, but obtained confidentially by the Figaro more CVR quotes from the Captain saying ” We’re no going to let some thunderstorms hassle us.” (original quotes in French “on va pas se faire emmerder par des cunimbs”) Also… Read more »
AS
Guest
I hope you’ve read the interim report (in French at first, and I believe an English version has since been posted). You have to read it, it paints quite a different picture than the 4-page English summary which in my opinion was worthless. There’s also a very interesting discussion on airliners.net that is quite interesting. Your conclusion of ‘I was right’ seems way oversimplified and in truth sounds wrong to me. The BEA facts are close to what you said. Pitot’s likely froze and caused autopilot to disconnect, pilots manually flew the aircraft from there. The plane stall and was… Read more »
Yousif
Guest

The previous report showed sudden stoppage of all electric sensors. That line of fault should have better been tackled from different angle. I think this accident and others along that longitude in the Atlantic ocean need more investigations and to be co-related to un-studied factor of the intense magnetic fields anomalies sometimes occurred along that line.

peter
Guest
As chief pilot in our company we did hands-on STALLS at 30,000ft + to experience the attitudes one can get into with very small stick movements,also the dreaded “coffin corner”.This was part of our training at the company’s expense. This kind of training should be for all Captains in all Airlines. One subject that has been omitted is the ITCZ. Having spent a third of my carreer in that zone and experienced some unbelievable weather conditions, I find it irresponsible that a Captain left the flight deck in the hands of such low flight time co-pilots. Their appears to have… Read more »
Brenan Newer
Guest

Poor passengers! They had to suffer for pilot error. Why don’t airlines train their employees before they handle real planes. Check everything necessary to avoid accidents.

Tansu
Guest
Just watched a documentary and the flight data and report about the accident. I’m sorry but the pilot named Bonin should not have been given the responsibility of not even a Cessna. Reading the transcript I wanted to cry upon the incapability of that guy. Look at this part. 02:13:40 Robert Remonte… remonte… remonte… remonte… Climb… climb… climb… climb… 02:13:40 Bonin Mais je suis à fond à cabrer depuis tout à l’heure! But I’ve had the stick back the whole time! OMG! The stall warnings coming on and off and you are pulling the stick the whole time???? I believe… Read more »
Tansu
Guest
Forgot to add. What the pilots needed to do (yeah I know it’s easier to say than to do) just ignore all error warnings and concentrate on attitude and the power of the aircraft ignoring all other messages from the control system. However, since they were not used to fly without the system, they still try to figure out what was wrong with the system and their brain froze out under the flow of so many errors. Instead, they should have ignored all the warnings and just constrate on manual flying. AFter flying so many times the same flights over… Read more »
Tansu
Guest

The letter of an A330 captain in the following link is very helpful.

My father was a A310 captain which had the early Airbus technology and had regular yoke rather than side stick like all new Airbuses. I remember he and his friends always praised Boeing for keeping the yoke and give feeling to the flight controls so pilots sense (especially the ones that come from military like my father) how the plane is reacting to the inputs.

This A330 captain kind of complains about the same thing.

http://grassrootsmotorsports.com/forum/off-topic-discussion/air-france-447-black-box-findings/36121/page1/

BMSQ
Guest
That’s the difference between European VS American Pilot/Manufacturer philosophy of seeing aviation business… When somebody doesnt trust on their pilots and intend to sell equipment that is able do devalue the human being in a way that pilot should be less taken care of and respected .( I’ve experienced both geographic sides of aviation ) Hiring less skilled and kowledgeable persons is the reason… Some others are pioneers on the business and know that there is no better device in an airplane than a human hand , so no room for forgetting skill Most of the latest accidents are due… Read more »
Norman
Guest
From the perspective of a non-pilot, intrigued by this crash of a sophisticated aircraft: A multiplicity of negative factors sealed the fate of this flight. The plane should have been grounded until the up-to-date Pitot tubes were replaced. There was no backup, no use of new doppler shift measurement by lasers now available. Current weather detection by satellites should have predicted the large thunderstorm and the flight should have been cancelled. The stall warning system was flawed so seriously that it was activated when the nose was pitched down and cancelled when the nose was pitched up. How crazy is… Read more »
ebenezer codjoe
Guest

lol